Patient Adherence to Oral Cancer Therapies: A Nursing Resource Guide

Christine Lombardi, MSN RN OCN
OncoLink
Last Modified: May 23, 2014

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Background

The use of oral cancer therapies for the treatment of cancer has experienced a rapid increase in recent years and this is expected to continue. An estimated 25% of anticancer therapies in the research pipeline have been designed for oral administration (Michaud & Choi, 2008). Putting the owness on the patient and caregiver to manage their cancer treatment, brings the issue of patient nonadherence and its' detrimental effect on patient outcomes, to the limelight. The issue of nonadherence with oral chemotherapeutic agents has been cited by the World Health Organization as the single most important yet modifiable factor that can compromise treatment outcomes. Oral therapies also change the site of care, from the cancer center infusion suite to the patient's home. This paradigm shift affects how oncology nurses will manage their patient's treatment and side effects. Nurses need resources that will assist them in promoting the importance of adherence to oral regimens and how this relates to improved patient outcomes. In a quantitative review of 50 years of research, related to a variety of diseases, DiMatteo, 2004, found that medication adherence is approximately 24.8%. Studies reported in recent Seminars in Oncology Nursing articles showed adherence rates ranging between 20%-100%. However, there was no consistent definition of adherence that was used in all of these articles, which may attribute to the wide variation in results.

Defining Adherence and Recognizing Its Prevalence

The World Health Organization ([WHO], 2003) defined adherence as the extent to which a person's behavior in taking medication or executing lifestyle changes agrees with recommendations from a healthcare provider. A patient is considered to be nonadherent if he or she misses doses, takes additional or wrong doses, as opposed to what is prescribed, or takes doses at the wrong time (Ruddy, Mayer, & Partridge, 2009). WHO projects that approximately 50% of patients typically take their medicines as prescribed. This percentage varies based on type of medication and disease. Patients with HIV, arthritis, GI disorders, and cancer have a higher incidence of adherence whereas those with diabetes and sleep disorders have a lower rate of adherence to medications. Adherence issues are not new—primary care providers (PCPs) have acknowledged that there is a high prevalence of nonadherence to treatment regimens for chronic diseases such as diabetes and heart failure. Oncology Health Care Providers (HCPs) generally assume that patients with cancer will adhere to treatment recommendations because of the seriousness of a cancer diagnosis; however, reports in the literature have demonstrated adherence levels as low as 20% (Lebovits et al., 1990; Partridge, Avorn, Wang, & Winer, 2002; Thompson, Dewar, Fahey, & McCowan, 2007). Adherence to prescribed cancer therapy is more than just taking your medicine on time—nonadherence can result in drug resistance, low response to therapy, disease progression, and death.

Barriers to Adherence to Oral Therapies

There can be a variety of barriers to adherence with oral oncolytic agents, some of which are listed below:

Types of Dimension Type of Barrier

Socioeconomic

  • Low language literacy
  • Lack of family or social support
  • Homelessness
  • Lack of health insurance/medication cost/copays
  • Limited access to a pharmacy
  • Busy work or social lifestyle

Healthcare System

  • Poor provider communication skills
  • Poor patient-provider relationship
  • Lack of knowledge on adherence
  • Lack of reinforcement from healthcare provider
  • Patient information materials written at a high literacy level

Disease

  • Asymptomatic
  • Severity of symptoms

Treatment Regimen

  • Complex regimen
  • Lack of quick benefit
  • Side effects
  • Requires significant behavioral changes

Patient related

  • Physical factors
  • Knowledge Deficit
  • Attitude, confidence, motivation
  • Psychological/behavioral/developmental factors
  • Perceived benefit of treatment
  • Fear of possible adverse effects
  • Stress/anxiety/anger
  • Alcohol or substance abuse

*This table is part of the ONS Oral Adherence Toolkit, see ONS website for the full kit.

Current Literature

According to Partridge, et al, there are practical recommendations for increasing adherence to oral chemotherapy agents. One recommendation being improved patient-provider communication and education. Oncology nurses have also begun to identify and address the challenges of supporting an increasing number of patients being treated with oral cancer agents. Spolestra, et al conducted an exploratory study on an intervention to improve adherence for patients who were prescribed oral chemotherapy agents. This 3 group pilot study evaluated how an Automated Voice Response (AVR) system with nursing interventions promoted adherence and managed adverse effects from oral chemotherapy. An AVR is an automated telephone system that uses voice-activated menus to drive the caller to specific information based on their response to the automated questions. The framework that was selected to be used for this study was called the Intervention for Symptom Management Model, developed by Given, et al. This model is based on a behavioral intervention framework for symptom management, which is grounded in cognitive modifications that lead to behavior change. Patients and their families are responsible for adherence to complex dosing regimens, monitoring symptoms, detection and management of adverse effects and toxicities, coordination of drug delivery and changes in dosing if altered or stopped by their HCPs. Interactive interventions used by the AVR system to manage symptoms experienced by cancer patients have demonstrated effectiveness. By using the AVR with nursing intervention strategy, this offered a combination of reinforcement, counseling, supportive care and telephone follow up, which guided these potentially nonadherent patients to address symptom severity, thus allowing nursing to intervene as appropriate.

Techniques for monitoring adherence to oral therapies

There are advantages and disadvantages of potential methods for monitoring patient adherence to medications. These can range from simple, non-invasive or inexpensive to costly and requiring a great deal of time and resources to carry out. They are described in the table below.

Direct Methods

Advantages

Disadvantages

Directly observed

Most accurate

Patients can hide pills and discard

Measurement of metabolite in blood

Objective

Variations in metabolism

Measurement of biologic marker in blood

Objective; in clinical trials

Requires expensive quantitative assays

 

Indirect Methods

Advantages

Disadvantages

Patient questionnaire

Patient self-report

Pill counts

Simple, inexpensive; most useful

Objective, easy to perform

Susceptible to error

Data can be altered by the patient (i.e.-pill dumping)

EMR monitoring

Rate of script refill

Assessment of the patient's clinical response

Tracks pattern of adherence

Objective and easy to obtain

Simple, easy to perform

Costly and requires return visits

May require access to pharmacy system

Factors other than adherence can affect clinical response

Measurement of physiologic markers

Patient diaries

Easy to perform

Helps to correct poor recall

Marker may be absent for other reasons (i.e.-lack of response)

Easily altered by the patient

*This table is part of the ONS Oral Adherence Toolkit, see ONS website for the full kit.

Developing a strategy

The Oncology Nursing Society (ONS) has developed an Oral Adherence Toolkit which provides strategies and resources that nurses can use to facilitate adherence among patients with cancer. The toolkit addresses:

  • Safety concerns: drug-drug and food-drug interactions, adverse effects
  • Pharmacy and reimbursement/financial resources
  • Monitoring of adherence
  • Motivational interviewing and counseling
  • Change theory and helping patients to change nonadherence into adherence

Nurses can utilize interventions to improve the patient-provider relationship with the ultimate goal of improving adherence. One of the strategies discussed in the ONS toolkit is motivational interviewing and counseling, which uses communication techniques as a nursing intervention to increase adherence.

Motivational interviewing uses more patient engagement, which may better contribute to improved adherence. Nurses can use several therapeutic skills during motivational interviewing, such as reflective listening and the use of open-ended questions, which can all assist with enhancing the nurse-patient collaborative partnership. According to Levensky et al 2007, nurses typically spend a significant amount of time trying to convince patients to change potentially harmful behaviors. Data has shown that behavior cannot be successfully modified unless patients set their own goals and see the value in change. Motivational interviewing respects patient self-determination, acknowledges autonomy, and recognizes that it is the patient who decides whether or not to change behaviors. It can be incorporated into normal conversation with the patient. Use of this technique can help engage and empower patients, thereby establishing a nurse patient relationship that can help patients achieve their personal goals. Traditional counseling is more health care provider driven, which offers less engagement on behalf of the patient and therefore may be less likely to improve adherence.

The concept of change theory can be applied to increasing medication adherence among patients as well. According to Prochaska et al, 2002, the Transtheoretical Model of Change, has been used to modify health behaviors. This model of change focuses on the decision-making abilities of the individual rather than the social and biological influences on their behavior. An example of how this model can be used with patients is as follows: A patient that is using intravenous drugs can be particularly resistant to drug treatment and may have no intention of quitting. Nurses would not encourage drug treatment for this patient; instead, they can focus on other behaviors for the patient such as HIV prevention. When the nurse counsels the patient, he or she can suggest general strategies to assist with modifying the risky behavior. Oncology nurses can apply this theory to cancer survivors by assessing the patient's readiness and intention to initiate and maintain an exercise program, and assist the patient in tailoring the program to their individual needs. This may be an important step in helping patients meet exercise guidelines and stay active.

Conclusion

With the rise in oral chemotherapy agents, nurses need to be aware that adherence to complex regimens can be difficult. Symptom management can go a long way in promoting adherence, and can be supported by nursing inventions, including education on potential side effects to notify the nurse for, frequent communication to monitor for side effects of therapy, and education on methods to managing these side effects. There are many resources that can guide nurses on how to assist their patients with medication adherence.

Physicians and advanced practice nurses prescribe oral agents for patients with cancer, but the decision about who will monitor the patient's adherence to therapy often remains debatable. Patients should be seen at least once per cycle for an assessment and pertinent laboratory testing. At that time, nurses can address questions about side effects and adherence with the patient. Between visits, nurses can contact patient's via the telephone and/or e-mail (if the practice permits electronic communication) to check on patients.

Oral therapy requires a multidisciplinary team approach for optimal safety and adherence: The physician, nurse, and pharmacist together can provide oversight for patients on home-based oral therapies. Nurses have always been key players in teaching patients about intravenous chemotherapy; however, many nurses feel less involved in oral chemotherapy teaching. Nurses are patient advocates. They can support good patient outcomes by participating in treatment monitoring, during the continuum of therapy, to increase adherence, promote safety, and evaluate side effects. Nurses can develop a structured plan of care for these patients during each patient appointment. This should include the following:

  • Assess and monitor adherence at each visit:
    • Ask about missed doses
    • Assess for barriers to adherence (i.e.: cost, side effects, schedule)
    • Work on resolving these barriers
  • Use telephone contact to monitor adherence of patients who visit the clinic less regularly, such as those receiving adjuvant long-term therapy or maintenance dosing.
  • Manage side effects early.

As mentioned, there are a number of direct and indirect techniques to monitor individual patient adherence to oral therapy, including pill counts, refill monitoring, patient self-report, and serum drug level testing. The techniques vary from noninvasive to invasive tests, and free to a significant cost to the patient or healthcare system.

Oncology nurses are in an ideal position to help patients identify their barriers to adherence and develop plans to deal with these barriers and improve adherence. Even when external barriers, such as access to medication, have been handled, patients may still face internal barriers such as lack of belief in the treatment or low motivation to stay on course through protracted or complicated medication regimens. Using appropriate interview techniques and helping patients recognize the need to change behavior are tools that oncology nurses can use to improve adherence.

References

Spoelstra, S. L., Given, B .A., Given, C. W., Grant, M., Sikorskii, A., Decker, V., You, M. (2013). An Intervention to Improve Adherence and Symptoms for Oral Oncolytics. Cancer Nursing, 36(1), 18-28.

Lebovits, A.H., Strain, J.J., Schleifer, S.J., Tanaka, J.S., Bhardwaj, S., & Messe, M.R. (1990). Patient noncompliance with self-administered chemotherapy. Cancer, 65, 17–22.

Michaud, L.B., & Choi, S. (2008, November 25). Oral chemotherapy: A shifting paradigm affecting patient safety. HemOnc Today.

Ruddy, K., Mayer, E., & Partridge, A. (2009). Patient adherence and persistence with oral anticancer treatment. CA: A Cancer Journal for Clinicians, 59, 56–66.

Thompson, A.M., Dewar, J., Fahey, T., & McCowan, C. (2007). Association of poor adherence to prescribed tamoxifen with risk of death from breast cancer [Abstract No. 130]. ASCO Breast Cancer Symposium.

World Health Organization. (2003). Adherence to long-term therapies: Evidence for action. Retrieved from: http://www.who.int/chp/knowledge/publications/adherence_report/en/index.html.

Oncology Nursing Society. (2013). Tools for oral adherence. Retrieved from: https://www2.ons.org/ClinicalResources/OralTherapies/media/ons/docs/clinical/AdherenceToolkit/toolkit.pdf.

DiMatteo MR. Variations in patients' adherence to medical recommendations: a quantitative review of 50 years of research. Med Care. 2004; 42(3): 200-209.

Partridge AH, Avorn J, Wang PS, Winer EP. Adherence to therapy with oral antineoplastic agents. Journal  of the National Cancer Institute 2002; 94(9): 652-661.

Given C, Given B, Rahbar M, et al. Effect of a cognitive behavioral intervention on reducing symptom severity during chemotherapy. Journal of Clinical Oncology. 2004; 22(3): 507-516.

Levensky et al, 2007; Miller & Rollnick, 2002; Possidente et al., 2005.

Prochaska et al., 2002; Prochaska & Velicer, 1997.


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Nov 24, 2014 - New strategies are needed to help cancer patients adhere to their oral chemotherapy regimens, according to "Compliance and Cost: Bitter Pills to Swallow in the Era of Oral Cancer Treatment," a session presented at the annual meeting of the American Society of Clinical Oncology, held from May 29 to June 2 in Orlando, Fla.



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